Senate readies for fight over patients' rights with HMOs

Judy Holland, EXAMINER WASHINGTON BUREAU

Published 4:00 am, Monday, July 12, 1999

1999-07-12 04:00:00 PDT UNITED STATES -- WASHINGTON - When the Senate this week considers regulating managed health care, the debate is expected to focus on questions of who should decide what medical treatment is appropriate - and what a patient unhappy with the decision can do about it.

Senate Republican leaders, insurers and business groups opposing more regulation of the health industry are pitted against Senate Democratic leaders, consumer groups and the American Medical Association urging Congress to guarantee broader rights for patients.

At the vortex is a proposal by Sen. Dianne Feinstein, D-Calif., that would allow a patient's doctor, not accountants or medical consultants hired to cut costs, determine when a treatment is medically necessary.

Feinstein complains that a physician who recommends medication, diagnostic tests or surgery is too often overruled by representatives of managed-care providers, HMOs or health insurance plans, who second-guess the decision in an effort to control costs.

If a health plan covers a treatment and a physician determines it is needed, the patient should be treated based on the illness, "not based on the calculation of a green eyeshade in a health insurance plan," Feinstein said.

"Insurance companies have invaded the examining room, the emergency room and the hospital room," said Feinstein, the daughter of a surgeon. Her first husband, the late Bert Feinstein, was a neurosurgeon.

Costs and benefits

But many Republican opponents, including Sens. Don Nickles, R-Okla., and Sen. Rick Santorum, R-Pa., warn that health care costs would skyrocket if insurers are unable to review the treatment decisions of physicians. They say it would be unfair to managed-care providers who must foot the bill if they are not able to double-check a doctor's recommendation.

Republicans argue that patients may benefit if the insurer takes a second look because physicians differ in their abilities. They also cite studies showing that doctors make different treatment decisions depending on the race or sex of the patient or the region of the nation.

Senate Republicans and Democrats also differ over what to do about patients who are denied coverage by their managed-care providers.

Democrats, led by Senate Minority Leader Tom Daschle, D-S.D., and Sen. Edward M. Kennedy, D-Mass., tell of patients who have lost their lives and limbs because managed-care providers wrongly denied coverage.

They want to change the law to allow a patient to sue managed-care providers in state courts for whatever damages are allowable under a state's law - if a patient was harmed because a treatment was wrongfully denied.

Federal law now bars patients with employer-provided health insurance from suing the managed-care provider for any damages beyond the cost of the wrongfully denied treatment.

"Americans and their businesses know they can be held accountable when they do something wrong," says Sen. Richard Durbin, D-Ill. "HMOs who make life-and-death decisions should be no different. It's time these insurance companies accept responsibility for their actions."

Insurers, business groups and Republican Senate leaders argue that expanding a patient's right to sue would lead to a flood of lawsuits, which would jack up health care costs. This in turn would cause more people to be uninsured because businesses won't be able to afford to provide health insurance, they say.

Remedies for the wronged

Instead, Republicans support a scaled-down approach to help patients fight back if they think they've been wrongfully denied treatment.

For example, an approach favored by Nickles and Rep. Jim Jeffords, R-Vt., would allow a patient to fight an adverse decision about coverage by appealing to an independent medical professional who would review a patient's appeal.

This outside reviewer, who would be hired by the provider, might be a health professional at an academic medical center who is a specialist in the appropriate field. The GOP proposal says an outside review would be invoked if the patient's health is in jeopardy and if the cost of treatment exceeds a "significant financial threshold" that would be set by the Secretary of Labor.

But Democrats, including Sens. Charles Schumer, D-N.Y., and John Edwards, D-N.C., say the Republican proposal is full of loopholes and doesn't guarantee a timely and fair appeal.

Edwards complains that the Republican proposal would allow managed-care providers to select the reviewer.

A coalition of business groups and health insurers has shelled out $750,000 for a media blitz that includes television and print ads depicting a hard-hat-wearing worker saying he doesn't know much about politics but that he fears politicians will pass laws to make his health insurance more expensive.

Chip Kahn, president of the Health Insurance Association of America, which represents 269 major insurance companies, said the Democratic proposals "would increase the cost of premiums and decrease the amount of covered Americans, particularly those who work for small business, because many businesses will drop their insurance plans."